Transcript
4-H MEDICAL INFORMATION AND INFORMED CONSENT FOR TREATMENT FOR NC 4-H SPONSORED EVENTS
PLEASE READ AND COMPLETE THE FOLLOWING FORM. THIS FORM MUST BE PRESENTED AT THE OFFICIAL REGISTRATION FOR THE 4-H SPONSORED EVENT BEING ATTENDED. I. Medical Information Known allergies to foods, drugs, insect stings or bites, etc:_________________________________ Special medical concerns or conditions that event supervisors should know about, including contagious illnesses, epilepsy, asthma, diabetes, previous injuries to bones/joints, etc.:
List special dietary needs: ____________________________________________________ Medications currently being taken (name of medication, dose, and frequency): ________________________________________________________________________________ Family Physician: Name __________________________________ Phone # (____) ____________ Address________________________________________________________________________
II. Insurance Information The 4-H program purchases insurance for youth participants for many sponsored events. In some cases, this coverage will not pay for some medical expenses and it may be necessary to bill the family or your insurance company. Health Insurance Company: _________________________________________________________ Health Insurance Policy # : __________________________________________________________ Company Address: ________________________________________________________________ Phone Company Telephone Number (____)_____________________________________________ III. If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in this activity, please contact __________ [name, office] at __________ [phone number/TTY] during business hours of 8 a.m. and 5 p.m. to discuss accommodations at least __________ [hours/days] prior to the activity.
Signatures Acknowledging Parts I, II, and III Parent's/Guardian's signature: _____________________________ Date:_____________________ Participant's Signature: ___________________________________ Date: ____________________ Parent/Guardian telephone #: Home _______________________ Work ______________________
1of 2 Must be completed each year by 4-H’er and Parent/Guardian. If health history changes within that year, it is the 4H’er & Parent/Guardian’s responsibility for updating information. Approved as of 3/02/06
IV. Informed Consent In the event that a participant needs minor medical care from 4-H or more significant medical care from a qualified heal care provider, including in rare cases possible hospitalization and/or surgery, the parent/guardian is asked to sign the informed consent form below. In case of serious medical condition, 4-H will make every effort to notify the parents, but the first priority may be providing care to the participant. Authorization to Consent to Health Care for Minor: I, _______________________________________, of ________________________ County, am the custodial parent having legal custody of _________________________, a minor child, age ________, born _____________________________. I authorize any adult(s) acting as agents (including official volunteers) or employees of the ________________________ 4-H program and in whose care the minor child has been entrusted , to do any acts which may be necessary or proper to provide for the health care of the minor child, including , but not limited to, the power (i) to provide for such health care at any hospital or other institution, or the employing of any physician, dentist, nurse, or other person for such health care, and (ii) to consent to and authorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or withdrawal of life sustaining procedures.
This consent shall be effective for one year from the date of the execution. Custodial Parent Signature: ______________________________________Date_______ STATE OF NORTH CAROLINA COUNTY OF _________________________ On this _________ day of ________________, 20___, personally appeared before me the said named, _____________________________, to me known and known to me to be the person described in and who executed the foregoing instrument and he (or she) acknowledged that he (or she) executed the same and being duly sworn by me, made oath that the statements in the foregoing instrument are true. My commission expires ____________________________________, 20_____. ___________________________ Notary Public ___________________________
(OFFICIAL SEAL)
2of 2 Must be completed each year by 4-H’er and Parent/Guardian. If health history changes within that year, it is the 4H’er & Parent/Guardian’s responsibility for updating information. Approved as of 3/02/06
